GI Board review: Part I By Molly McVey.

Similar presentations

Presentation on theme: "GI Board review: Part I By Molly McVey."— Presentation transcript:

2 Esophagus Symptoms of esophageal disorders: Dysphagia RefluxOropharyngeal – diagnostic test is videofluoroscopyEsophageal – diagnostic test is upper endoscopyRefluxChest painOdynophagiaGlobus sensationOropharyngeal or transfer dysphagia is characterized by difficulty in the initial phase of swallowing, in which the bolus is formed in the mouth and is transferred from the mouth through the pharynx to the esophagus.Esophageal dysphagia is characterized by difficulty in passage of the bolus through the esophagus.Globus sensation is the awareness of a lump or tightness in the throat that is unrelated to meals or swallowing.

3 Diffuse esophageal spasm Eosinophilic esophagitis Schatzki ringA 35-year-old man is evaluated for a 2-year history of intermittent chest pain. The pain is retrosternal, lasts for seconds to minutes, is unrelated to exertion, and does not radiate. It is occasionally associated with swallowing. He reports intermittent dysphagia to solids and liquids. He denies any reflux symptoms or weight loss. He does not have any risk factors for cardiac disease. Physical examination is unremarkable. Upper endoscopy is normal. A barium swallow is shown. Which of the following is the most likely dignosis?AchalasiaDiffuse esophageal spasmEosinophilic esophagitisSchatzki ring

6 Eosinophilic esophagitis Esophageal candidiasis Esophageal malignancy A 25-year-old man is evaluated for a 5-year history of slowly progressive solid-food dysphagia that is accompanied by a sensation of food sticking in his lower retrosternal area. He has compensated by modifying his diet and avoiding fibrous meats. He has not lost weight, and he has not had trouble drinking liquids. He has had episodes of food impaction that he manages by inducing vomiting. He has had no difficulty initiating a swallow and has not had chest pain, odynophagia, reflux symptoms, or aspiration of food while swallowing. He has seasonal allergies that are treated with antihistamines and asthma that is treated with inhaled albuterol. Physical examination is normal. Which of the following is the most likely diagnosis?AchalasiaEosinophilic esophagitisEsophageal candidiasisEsophageal malignancyOropharyngeal dysphagia

8 Ambulatory pH study Begin an NSAID Endoscopy Trial of a PPIA 50-year-old woman is evaluated for a 1-year history of recurrent left-sided chest pain. The pain is poorly localized, nonexertional, and occurs in 1-minute episodes. There is no dyspnea, nausea, or diaphoresis associated with these episodes. She has not had dysphagia, heartburn, weight change, or other gastrointestinal symptoms. She has no other medical problems and does not smoke cigarettes. Family history is noncontributory. On physical examination, vital signs are normal and BMI is 30. The patient's chest pain is not reproducible with palpation. The cardiac examination reveals normal heart sounds without murmurs or extracardiac sounds. The remainder of the physical examination is normal. A lipid panel, fasting plasma glucose test, and chest radiograph are normal. An echocardiogram shows a normal ejection fraction with no wall motion abnormalities. An exercise stress test is normal. Which of the following is the most appropriate management?Ambulatory pH studyBegin an NSAIDEndoscopyTrial of a PPI

9 Nonmalignant esophageal disorderGERDSymptoms: heartburn and regurgitationDx: symptoms, endoscopy or ambulatory pH monitoringEmpiric tx first if not effective then endoscopyAlarm symptoms (dysphagia, anemia, vomiting or weight loss)Endoscopy is first lineAmbulatory pH monitoring: don’t respond to tx and endoscopy is unremarkableTx:Lifestyle modificationsMedications: PPI superior to H2BsPPI may increase susceptibility to GI infections (C.diff) and pneumoniaUnclear data on increase risk of hip fractureFundoplicationFundoplication: for refractory reflux, PPI intolerance or allergy, or don’t want life long meds

10 Daily COX-2 inhibitor therapy Endoscopic ablation Fundoplication A 55-year-old man is evaluated for a 6-year history of typical gastroesophageal reflux symptoms treated on an as-needed basis with a proton pump inhibitor. However, the frequency of his reflux symptoms has recently increased and his episodes do not respond to treatment as completely as in the past. An upper endoscopy is scheduled to evaluate the cause of this change in his symptoms. Endoscopy reveals a 4-cm segment of salmon-colored mucosa in the distal esophagus. Biopsy from the salmon-colored segment reveals intestinal metaplasia and goblet cells with no dysplasia. In addition to starting a daily PPI, which of the following is the most appropriate management?Daily COX-2 inhibitor therapyEndoscopic ablationFundoplicationRepeat endoscopy in 1 year

11 CT/PET and endoscopic US Esophagectomy Feeding tube placement A 75-year-old man is evaluated for a 2-month history of progressive solid-food dysphagia. He has transitioned from solid to puréed foods and has been able to maintain his weight. He has a 40-pack-year history of cigarette smoking and a history of alcohol abuse. On physical examination, vital signs are normal. BMI is 35. There is no evidence of supraclavicular lymphadenopathy. Cardiopulmonary examination is normal. On abdominal examination, there is no evidence of mass, tenderness, or hepatomegaly. A complete blood count reveals a hemoglobin level of 10.9 g/dL (109 g/L). Endoscopy reveals an obstructive mass in the distal esophagus, and biopsies show invasive adenocarcinoma. Which of the following is the most appropriate management?CT/PET and endoscopic USEsophagectomyFeeding tube placementRadiation therapy

12 Malignant Disorders of the EsophagusBarrett EsophagusComplication of GERD30-50 fold increased risk of esophageal adenocarcinomaScreening is not recommendedDx: biopsyTx:PPI ? Lower risk of developing high grade dysplasiaAblative therapies for high grade dysplasiaSurveillance:No dysplasia: repeat endoscopy in 1 yearLow grade: repeat endoscopy in 6 monthsHigh grade: removal of focal lesionsCont to treat reflux with PPIFundoplication has not been shown to reduce risk of progression

14 H.pylori stool antigen testing Initiate an H2 blocker A 44-year-old woman is evaluated for a 1-year history of vague upper abdominal discomfort that occurs after eating. She is from a rural area in a developing country. She has not had nausea, vomiting, dysphagia, odynophagia, weight loss, or black or bloody stools. She is otherwise healthy. She has no personal history of peptic ulcer disease and no family history of gastrointestinal malignancy. Her only medication is a multivitamin. On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 127/82 mm Hg, pulse rate is 72/min, and respiration rate is 16/min. BMI is 27. There is epigastric tenderness with moderate palpation but no masses or lymphadenopathy. Complete blood count is normal. Which of the following is the most appropriate management?H.pylori stool antigen testingInitiate an H2 blockerInitiate empiric treatment for H.pylori infectionPerform endoscopyDyspesia – caused by PUD and h.pylori<50 without alarming symptoms (anemai, dysphagia, odynophagia, vomiting, weight loss, family history of GI malignancy, person history of PUD, gastric surgery or GI malignancy or abdominal mass or LAD on exam) then test and treat for H.pylori or empirically treat with PPITest and treat for h.pylori if coming from area with high rates of h.pyloriEmpiric PPI in areas where h.pylori rates are low

15 Dyspepsia PUD and h.pyloriAlarming symptoms: >50 yo, anemia, dysphagia, odynophagia, vomiting, weight loss, family history of GI malignancy, person history of PUD, gastric surgery or GI malignancy or abdominal mass or LAD on exam< 50yo and no alarming symptoms:Test and treat for h.pylori if coming from area with high rates of h.pyloriEmpiric PPI in areas where h.pylori rates are lowAlarm symptoms then straight to endoscopy

19 Cannabinoid hyperemesis syndrome Chronic intestinal pseudo-obstruction A 26-year-old man is evaluated for a 16-month history of intermittent episodes of abdominal discomfort, nausea, and vomiting. He is relatively asymptomatic between episodes, which occur every 4 to 6 weeks. Episodes consist of vomiting once every 2 to 4 hours for about 48 hours. The only relieving factor is hot baths. He currently feels well, but it has been 5 weeks since his last episode. His medical history is notable for daily marijuana use for the past 2 years. On physical examination, vital signs are normal. BMI is 25. Abdominal examination is normal. Laboratory studies reveal a normal complete blood count and normal plasma glucose and thyroid-stimulating hormone levels. An abdominal radiograph is normal. Which of the following is the most likely diagnosis?Cannabinoid hyperemesis syndromeChronic intestinal pseudo-obstructionCyclic vomiting syndromeGastroparesis

21 CT of the head Glucose infusion IV naloxone IV thiamineA 34-year-old man is evaluated in the emergency department for confusion. Three weeks ago he underwent a Roux-en-Y gastric bypass for morbid obesity. He has had poor oral intake since the surgery because of nausea. Vitamin B12 injections were prescribed, but he has not started them yet. He recently took hydrocodone for pain, but he has not needed it for several days. His only current medication is a multivitamin with iron. On physical examination, he is afebrile. Blood pressure is 115/80 mm Hg (no orthostatic changes), and pulse rate is 85/min. The mucous membranes are moist, and there is no skin tenting. He has an ataxic gait, nystagmus, and a disconjugate gaze. The remainder of the neurologic examination is normal. Laboratory studies, including a complete blood count, glucose, and electrolytes, are normal. Which of the following is the most appropriate next step in management?CT of the headGlucose infusionIV naloxoneIV thiamineSubcutaneous Vit B12Clinical featuers of thiamine deficiency manifesting as Wernicke encephalopathy (nystagmus, ophthalmoplegia, ataxia and confusion)

23 Percutaneous drainage Surgical drainage A 42-year-old woman is evaluated following hospitalization for acute pancreatitis due to gallstone disease that occurred 8 weeks ago. An admission CT scan demonstrated no evidence of fluid collection or necrosis, and she had an uncomplicated cholecystectomy prior to discharge. She has no pain, nausea, or anorexia. However, 2 weeks ago she was evaluated for nephrolithiasis following an episode of renal colic and underwent a CT scan. The CT scan demonstrated a 4-mm stone in the right ureter and a 6-cm fluid collection adjacent to the pancreatic tail. There was no evidence of solid debris, and it did not communicate with the main pancreatic duct. There were no mass lesions in the liver and no pancreatic necrosis. She has since passed the kidney stone and is asymptomatic. On physical examination, temperature is 37.2 °C (99.0 °F), blood pressure is 112/72 mm Hg, pulse rate is 66/min, and respiration rate is 18/min. BMI is 25. Abdominal examination discloses a nondistended abdomen and active bowel sounds. There is no tenderness to palpation, hepatosplenomegaly, or masses. Laboratory studies, including complete blood count, liver chemistry tests, CA 19-9, and alkaline phosphatase, are normal. Which of the following is the most appropriate next step in management?Endoscopic USMRCPPercutaneous drainageSurgical drainageNo further diagnostic testing or therapy

26 Perform endoscopic US of pancreas Refer for pancreaticoduodenectomyA 72-year-old man is evaluated for a 2-week history of painless jaundice. He also has pruritus, anorexia, and weight loss of 4.5 kg (10.0 lb) during the same time period. He takes no medications. On physical examination, vital signs are normal. BMI is 22, and he appears thin. Scleral icterus and jaundice are present. There is no hepatosplenomegaly and no cutaneous signs of cirrhosis. The gallbladder is palpable.Laboratory studies:Complete blood countNormalAlkaline phosphatase522 units/LAlanine aminotransferase354 units/LAspartate aminotransferase215 units/LTotal bilirubin12.1 mg/dL (206.9 µmol/L)Direct bilirubin10.7 mg/dL (183.0 µmol/L)Contrast-enhanced CT scan demonstrates a dilated common bile duct with focal cutoff in the pancreas head. No focal mass is noted in the head. The pancreas duct is dilated. There is no evidence of mass lesions in the liver.Which of the following is the most appropriate initial management?In elderly patients with painless jaundice and a focal cutoff sign of the bile and pancreas ducts with upstream dilation, pancreatic malignancy is the most likely differential diagnosis. EUS is as accurate as CT for detecting tumors and may be more sensitive for tumors smaller than 2 cm in diameter. EUS with fine-needle aspiration biopsy can provide specimens for histologic evaluation.MRI is unlikely to be any more successful in detecting a pancreatic tumor than was the CT scan.Obtain serum CA19-9Perform abdominal MRIPerform endoscopic US of pancreasRefer for pancreaticoduodenectomy

29 Operative pancreatic exploration Pentetreotide scintigraphy23-year-old woman is evaluated in the hospital for recurrent episodes of hypoglycemia. During hospitalization, she developed neuroglycopenic symptoms after 8 hours of fasting associated with a plasma glucose level of 30 mg/dL (1.7 mmol/L) and a corresponding insulin level of 8 µU/mL (58 pmol/L). She does not have diabetes mellitus and does not take oral hypoglycemic agents or insulin. On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure is 90/56 mm Hg, pulse rate is 110/min, and respiration rate is 22/min. BMI is 22. No tenderness, masses, or hepatosplenomegaly is found on abdominal examination. A contrast-enhanced CT scan demonstrates no evidence of a pancreatic mass. Which of the following is the most appropriate diagnostic test to perform next?Endoscopic USMRIOperative pancreatic explorationPentetreotide scintigraphyInsulinoma: fasting hypoglycemia (<45), symptoms and inappropriate hyperinsulinemia (insulin level >5-6)Although these lesions are missed on CT scans if they are smaller than 2 cm, this modality is essential to exclude larger lesions or those already metastatic to the liver. If there are no significant findings, further evaluation may include EUS of the pancreas, hepatic venous sampling with arterial calcium stimulation, or pancreatic arteriography. Of these tests, the least invasive is EUS, which has an approximately 90% detection rate for insulinomas.MRI would not offer any diagnostic benefit over CT in this situation.

31 Fecal leukocyte testing Flexible sigmoidoscopy with biopsies A 34-year-old woman is evaluated in an urgent care clinic for a 1-day history of watery diarrhea and mild abdominal cramps. She is having four watery stools per day. She has not had fever or blood in her stool. Although she has felt mildly nauseated, she has been able to stay hydrated with oral intake. She works as a banker, and colleagues at work have had similar gastrointestinal symptoms over recent weeks. She has no history of recent hospitalization, antibiotic use, or medication changes. She has no risk factors for HIV infection. On physical examination, temperature is 36.1 °C (97.0 °F), blood pressure is 110/75 mm Hg, pulse rate is 86/min, and respiration rate is normal. BMI is 24. The mucous membranes are moist, and there is no skin tenting. Abdominal examination reveals mild abdominal tenderness but normal bowel sounds. There is no guarding or rebound. A urine pregnancy test is negative. Which of the following is the most appropriate diagnostic test?C.diff PCRFecal leukocyte testingFlexible sigmoidoscopy with biopsiesGeneral stool bacterial culturesNo additional studies

33 Repeat upper endoscopy with small-bowel biopsies A 26-year-old man is evaluated for fatigue and has been newly diagnosed with iron-deficiency anemia. The patient has Down syndrome, and details of his clinical history are provided by his mother. There is no history of melena, hematochezia, or hematuria. His hemoglobin level was checked 2 years ago and was normal. His bowel movements are regular, and his weight is unchanged. He has no abdominal problems. On physical examination, temperature is 36.3 °C (97.3 °F) and pulse rate is 88/min. Other vital signs are normal. BMI is 29. Mild skin pallor is noted. Abdominal and rectal examinations are normal. Serum tissue transglutaminase IgA antibody testing is negative. Colonoscopy and upper endoscopy are unremarkable. Which of the following is the most appropriate diagnostic test to perform next?Meckel scanPush enteroscopyRepeat upper endoscopy with small-bowel biopsiesSmall-bowel capsule endoscopyStool guaiac examinationConsider celiac in all patients with IDA, increased risk of developing celiac in Down syndrome patients- Need small bowel biopsies even if tTG antibody is negative

35 Celiac disease Symptoms: diarrhea, bloating and weight lossExtraintestinal: anemia, osteopenia/porosis, dematitis herpetiformis…Associated with Down syndrome, type 1 DM, juvenile RA, thyroid dz and AI liver conditionsDx: tTG IgA antibody (false negative in IgA deficiency)Tx: gluten-free dietThe best serologic test to screen for celiac disease is the tissue transglutaminase (tTG) IgA antibody, but the sensitivity (69%-93%) and specificity (96%-100%) vary significantly among laboratories. IgA-based tTG testing may result in false negatives in the small proportion (<5%) of patients who have selective IgA deficiency; however, it is more useful for screening than an IgG-based tTG, which has poor sensitivity in non–IgA-deficient patients.

36 Lactose malabsorption Microscopic colitis A 51-year-old woman is evaluated for a 6-month history of diarrhea and bloating. She reports four to six loose stools per day, with occasional nocturnal stools. She has had a few episodes of incontinence secondary to urgency. She has not had melena or hematochezia but notes an occasional oily appearance to the stool. She has lost 6.8 kg (15.0 lb) during this time period. Results of a colonoscopy 1 year ago were normal. She has not had recent travel, antibiotic use, or medication changes. She does not think consumption of dairy products alters her symptoms. She has a history of systemic sclerosis for which she takes omeprazole for symptoms of gastroesophageal reflux disease. On physical examination, vital signs are normal. BMI is 22. Facial telangiectasias are present, and there is bilateral skin thickening of the hands. The abdomen is mildly distended, and bowel sounds are normal. Rectal examination is normal, with normal resting and squeeze tone. There are no palpable mass lesions.Laboratory studies:Hemoglobin10.8 g/dL (108 g/L)Mean corpuscular volume104 fLSerum electrolytesNormalFolate63 ng/mL (143 nmol/L)GlucoseThyroid-stimulating hormoneVitamin B12118 pg/mL (87 pmol/L)Tissue transglutaminase antibodyStool cultures, including an ova and parasite examination, are normal.Which of the following is the most likely diagnosis?IBS: no weight loss or noctural stoolsLactos malabsorption: no weight no lossCeliac diseaseIBSLactose malabsorptionMicroscopic colitisSmall intestinal bacterial overgrowth

About project

Feedback

To ensure the functioning of the site, we use cookies. We share information about your activities on the site with our partners and Google partners: social networks and companies engaged in advertising and web analytics. For more information, see the Privacy Policy and Google Privacy &amp Terms.
Your consent to our cookies if you continue to use this website.